CMS releases additional information on the new expedited conditional payment process

By Mark Popolizio December 29, 2015

On December 21, 2015, the Centers for Medicare and Medicaid Services (CMS) released additional information regarding its continued implementation of the new expedited conditional payment process, set to begin on January 1, 2016. The latest release from CMS includes updates to information it posted in November.

Under the new process, parties will now be able to obtain Medicare’s “final” conditional payment amount through the Medicare Secondary Payer Recovery Portal (MSPRP) prior to settlement, judgment, award, or other payment as required under Section 201 of the SMART Act.

Here are the updates per the November and December CMS notices:

  • Authorized MSPRP users will notify CMS that a recovery case is 120 days (or less) from anticipated settlement in order to request that the recovery case be part of the final conditional payment process.
  • When the final conditional payment process is requested, any disputes submitted through the MSPRP will be resolved within 11 business days of receipt of the dispute.
  • Once all disputes have been resolved and the case is within three days of settlement, the beneficiary or their representative will be able to request a final conditional payment amount through the MSPRP.

Once CMS calculates the final conditional payment figure, the amount will remain the final amount so long as:

  • The case is settled within three calendar days of requesting final conditional payment amount; and
  • Settlement information is submitted through the MSPRP within 30 calendar days of final conditional payment amount request.

The request for the final conditional payment amount can be made only once per case. If the case is not settled within the three days and/or the settlement information is not submitted through the MSPRP within 30 calendar days, then the final conditional payment process will be voided. At that point, new claims may be added and the conditional payment amount modified accordingly. Further, any subsequent disputes will not be held to the 11-day resolution timeline.

In addition, insurers and their authorized representatives can initiate the final conditional payment process on their insurer-debtor cases, so long as a settlement is pending and no outstanding ongoing responsibility for medicals (ORM) exists. Once the final conditional payment process has been started on an insurer-debtor case, the following will occur:

  •  The insurer-debtor case will be closed and the debt will be transferred to a new case where the beneficiary is the identified debtor.
  •  The insurer and their authorized representatives will not be able to work the new beneficiary-debtor case or receive copies of any recovery-related correspondence related to the new beneficiary-debtor case until they obtain and submit an authorization signed by the beneficiary.

A copy of the December CMS notice can be obtained here

Practical Considerations

The expedited conditional payment process will be a useful tool most notably in resolving liability claims. However, it may be challenging to use the expedited conditional payment process in workers' compensation claims, specifically, where ORM still exists. Given that most WC claims technically have ORM through settlement under the Section 111 process, it is uncertain at this point how workers' compensation payers will be able to benefit from this process. Also, the associated timelines as noted above may prove problematic in the WC setting. In this regard, further clarification (and perhaps adjustment) from CMS may be needed to ensure that all programs benefit from this process.

ISO Claims Partners will continue to monitor developments and provide future updates as warranted. In the meantime, please feel free to contact Mark Popolizio with any questions at 978-825-8186 or e-mail mpopolizio@iso.com.


Mark Popolizio

Mark Popolizio is the Vice President of MSP Compliance and Policy for ISO Claims Partners. Mark’s area of specialty is Medicare secondary payer compliance. He authors regular articles and provides educational presentations across the country on MSP issues. Mark's e-mail address is mpopolizio@iso.com.